6 Effects of Chronic Heavy DrinkingFaculdade de Medicina de Ribeirão Preto - USPEffects of Chronic Heavy DrinkingCNSNeuropathiesCerebellar degenerationDementiaWernicke-Korsakoff’s syndromeSLIDE 7. Again we return to the central nervous system. Chronic heavy alcohol use has many CNS effects. So the next time you have a patient in your office with numbness or tingling in her extremities (i.e., a peripheral neuropathy), consider alcohol dependence in the differential diagnosis along with the usual suspects like diabetes, HIV, primary neurological conditions, and toxic/metabolic causes.In addition, chronic alcohol use can cause gait disturbances associated with cerebellar damage and memory problems of a variety of sorts.A word about Wernicke-Korsakoff’s syndrome – very few alcoholics ever get this – I’ve seen probably 5 cases in my career thus far. The primary pathophysiology is thiamine deficiency due to malabsorption in the GI tract in alcoholics, leading to degeneration of the mamillary bodies of the limbic system and other brain structures (dorsomedial nucleus of thalamus and periventricular grey matter). These individuals have a remarkable presentation of confusion, nystagmus, and some paralysis of ocular muscles, and if not corrected (with thiamine administration) can progress to permanent severe short term memory loss and confabulation. But remember, this is a very rare condition.Next time someone comes into your office for numbness and tingling in their hands and feet, consider not only DM and toxic/metabolic causes, but also consider alcohol dependence (can get GGT and MCV along with HgA1C)Cortical dementia from long-term consumption of large amounts of alcoholWernicke-Korsakoff’s – thiamine deficiency, related to impaired intestinal absorption of thiamine with heavy drinking

13 Alcohol and NeuroadaptationFaculdade de Medicina de Ribeirão Preto - USPAlcohol and Neuroadaptation

14 Faculdade de Medicina de Ribeirão Preto - USPEvolução Conceitual1791 – Benjamin Rush“Drinking began as na act of free will, descended into a habit and finally sank to a necessity”1804 – Thomas Trotter“However seducing the love of inordinate drinking may be, like other bad habits, men seldom get into it at once. There is a gradation in the vice”

21 Sra. Maria da Silva, 38 anos, professora do ensino médioFaculdade de Medicina de Ribeirão Preto - USPSra. Maria da Silva, 38 anos, professora do ensino médioDores abdominais recorrentesEstresse e ansiedade relacionados ao trabalhoInsônia IntermitenteIrritabilidadeGastrite – diagn. sob gastroscopiaHipertensão intermitenteSlide 2: A national survey by the National Center on Addiction and Substance Abuse at Columbia University examined how primary care physicians deal with patients who have substance abuse problems. This survey reveals how physicians identify - or fail to identify-substance abuse in their patients. The most troubling finding of this survey is that 94% of primary care physicians failed to include substance abuse among the five diagnoses they offered when presented with early symptoms of alcohol abuse in an adult patient.Other findings include:Less than 1/3 of primary care physicians carefully screen for substance abuseMost patients (54%) with substance abuse said their physicians did nothing about their abuseOnly 20% of physicians consider themselves very prepared to identify alcoholismOnly 4% of physicians think treatment for alcoholism is very effective. In contrast, physicians consider treatments for other chronic conditions such as hypertension (86%) and diabetes (69%) very effective.Survey Question: Based on your experience, I’d like to ask you to suggest up to five likely diagnoses that come to mind for the following hypothetical patient:The patient is a married, 38 year old woman with recurrent abdominal pains and is not pregnant. She is employed as a high school teacher and reports job related anxiety and stress. She has intermittently elevated blood pressure, and gastritis visible on gastroscopy, as well as waking up frequently at night and irritability. She also reports normal libido, and no previous psychiatric history.

23 Faculdade de Medicina de Ribeirão Preto - USPDependência ao ÁlcoolDependência ao Álcool é uma síndrome clínica, na qual identificamos um conjunto de sintomas relacionados ao consumo de álcool.A Dependência ao Álcool tem os sintomas chave: tolerância, reação de abstinência e uso compulsivo ou sem controle.A despeito da presença de problemas, clínicos ou sociais, o dependente continua a fazer uso do álcool.Slide 4: Alcohol dependence is a clinical syndrome in which there is a cluster of alcohol related symptoms. Despite problems with alcohol, an individual continues to drink. The criteria for alcohol dependence are:A maladaptive pattern of alcohol use, leading to clinically significantimpairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12 month period:(1) tolerance, as defined by either of the following:(a) a need for markedly increased amounts of alcohol to achieve intoxication or desired effect(b) markedly diminished effect with continued use of the same amount of alcohol(2) withdrawal, as manifested by either of the following:(a) a characteristic withdrawal syndrome for alcohol(b) alcohol use to relieve or avoid withdrawal symptoms(3) alcohol is often taken in larger amounts or over a longer period than was intended(4) there is a persistent desire or unsuccessful efforts to cut down or control alcohol use(5) a great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects(6) important social, occupational, or recreational activities are given up or reduced because of alcohol use(7) alcohol use is continued despite knowledge of having a persistent or recruuent physical or psychological problem that is likely to have been caused or exacerbated by alcohol

24 Faculdade de Medicina de Ribeirão Preto - USP“Beber de Risco”“Beber de Risco” é um padrão de consumo de álcool que é diretamente prejudicial, ou está relacionado com um maior risco de problemas de saúde.Homens: > 14 drinks por semana5 ou mais drinks por ocasiãoMulheres: > 7 drinks por semana4 ou mais drinks por ocasiãoSlide 5: “At risk drinking is a level of “At risk drinking” is a level of alcohol consumption that is directly harmful or is correlated with a greater risk for the development of health problems. “At risk drinking” is defined for men and women as follows:MenGreater than 14 drinks per week5 or more drinks per occasionWomenGreater than 7 drinks per week4 or more drinks per occasion

26 Avaliação para “Beber de Risco” e Dependência ao ÁlcoolFaculdade de Medicina de Ribeirão Preto - USPAvaliação para “Beber de Risco” e Dependência ao ÁlcoolCom que freqüência você bebe bebidas alcoólicas (chope, cerveja, “ice”, vodka, pinga, licores, batidas, etc.)?Quantos drinks contendo álcool você ingere em um dia normal em que você sai para beber?Com que freqüência você ingere seis ou mais drinks em uma única ocasião ?Slide 7: Time is of the essence in medical practice and screening can be done effectively by asking three questions relating to amount of alcohol consumption .How often do you have a drink containing alcohol?(0) Never(1)Monthly or less(2)2 to 4 times a month(3)2 to 3 times a week(4)4 or more times a weekHow many drinks containing alcohol do you have on a typical day when you are drinking?(0)1 or 2(1)3 or 4(2)5 or 6(3)7, 8, or 9(4)10 or moreHow often do you have six or more drinks on one occasion?(0)Never(1)< Monthly(2)Monthly(3)Weekly(4)Daily or almost dailyBy adding the numbers of each answer, a score is developed that ranges from 0 to 12. Using a cutoff of 3 or more, 90% of current alcohol dependent individuals are detected and 98% of heavy drinkers are detected .

27 Faculdade de Medicina de Ribeirão Preto - USPIntervenção BreveMais frequentemente utilizada em pacientes sem dependênciaGeralmente 4 sessões ou menosA sessão dura entre poucos minutos a uma hora de duraçãoConduzida por profissionais de saúde não-especialistas em farmacodependênciasSlide 8: Brief interventions are often used by primary care physicians and can be effective in non alcohol dependent subjects. Most interventions are 4 sessions or fewer and are even effective if they are just a few minutes.

34 Faculdade de Medicina de Ribeirão Preto - USPRehabilitationIncrease motivationHelp rebuild lifeRelapse Prevention+/- medicationsThis template was created by using a black background. The bottom stripes were created by drawing an opaque rectangle on a vertical shaded background and copying and pasting it as a picture onto the master slide. Black diagonal lines were then drawn over the shaded object to create the striped effect.